Oral surgery block 1 Flashcards
What instruments are needed for suturing
Tissue forceps – for manipulating tissue. Held in pen grip in non-dominant hand
Needle holders – for holding the suture needle. Thumb and 4th finger in rings, use index finger to support the shaft
Scissors – for cutting the suture
Suture – larger the number, the smaller the suture diameter. Suture needle with inside cutting edge to help pass through the tissue.
Key steps in doing a suture
-Needle is passed through tissue at 90 degrees to the tissue surface. At least 3mm from wound edge. Needle then passed through the other side of wound. Pull all the way through so only a little tail left on one side.
-Tie a surgeon’s knot by wrapping the suture round the needle holders twice. The needle holders go on the inside of the “valley”. The free end of the suture is then grasped by the needle holders, and the knot is slid down towards the wound. Put the little tail on the opposite side to what it was.
-It will need a few more knots to secure (depends on the type of suture).
-Too tight may cause tissue necrosis, too loose may prevent wound healing. When doing multiple sutures, make sure the knots are placed at the same side of the wound. Cut excess suture. Dispose of the needle in sharps bin
What are the 3 stages of haemostasis
- Vasoconstriction: reduces blood flow
- Platelet aggregation and adhesion- platelet plug forms within a 5-10 minutes to stop further blood loss and protect the wound from contamination. But it is unstable and easily dislodged. Dead as no blood supply
- Clotting cascade to produce fibrin- fibrin is incorporated into and around the plug to strengthen and stabalise the clot. It takes about 24 hours to form a mature clot
3 functions of a clot
- Arrest haemorrhage
- Protect the wound from contamination
- Provide substrate for further healing to take place
What is done/ not done to help form the clot and keep it in
To help form a clot= compress the socket with gauze for 5-10 mins
To help keep the clot = no smoking, no vigorous exercise for 24 hrs (increases BP), no rinsing for 24 hours (salt water after this), gentle cleaning around the area, no aspirin (anti-platelet), avoid oral contraceptive pill, avoid alcohol (vasodilation), avoid eating whilst numb
What is granular tissue. When and how is it formed. Is it dead or alive
-The fate of the clot is to be replaced by granulation tissue, which is rich in blood supply and fibrous tissue
-The blood supply migrates from surrounding tissue (i.e. bone and gingivae) whilst dead cells are removed by macrophages.
-It takes 5-10 days to establish mature granulation tissue.
-function of granular tissue= continue protective function, allow further repair to occur, establish ideal vascular bed for epithelial coverage to advance from edges of wound
-has rich blood supply so a living tissue
What is epithelialisation and keratinisation, when it occurs
-migration of epithelium occurs very quickly once blood supply is present
-takes around 2-3 weeks after extraction
-Epithelial coverage of wound re-establishes the integrity of the host. Initially it is only very thin, so easily damaged. The wound may still appear red.
-The Epithelium will eventually start to keratinize. -keratinisation is the thickening of epithelium to protect itself from trauma
when is early osteoid seen. when will cortical bone in the socket remain
-after 3 weeks
-for years, especially in the elderly
what is a dry socket and how does it present and when
-if the clot fails to form or dislodges this exposes bone and causes localised bone inflammation = alveolar osteitis. It is not an infection, so no antibiotics
-usually 2-5 days after extraction.
-the patient will have felt reduced pain following tooth extraction, but dry socket pain may be described as worse than the initial toothache.
-The patient may not be able to prevent food or debris entering the socket once the clot is lost and the stimulation of the exposed bone results in frequent bursts of acute pain.
-The surrounding areas may be touched without eliciting the pain, but contact with the exposed bone will result in pain.
Incidence and causes of a dry socket. Risk factors
Incidence - approximately 1-5% of all extractions, but up to 38% of mandibular 3rd molar extractions (due to poor blood supply).
Causes- Traumatic extractions are more likely to result in a dry socket. This may be due to more local damage to the alveolar bone in the socket. Smoking has a vasoconstrictive effect, and the sucking action when drawing a cigarette may increase risk of loss of the clot.
A compromised immune system, bleeding disorders, the pill may increase the risk of dry socket occurrence.
mandibular 8 most common tooth
Management of a dry socket
-Irrigation to remove debris, food, plaque. With or without local anaesthesia with saline (first choice) or CHX 0.2% (anti-bacterial, but avoided in allergic patients, or those patients with allergic tendencies)
-A dressing is then placed to cover the exposed bone-Alveogyl which is a resorbable dressing containing Iodoform (antimicrobial), Eugenol and Butamben (anaesthetic).
[ Alvogyl is discontinued due to iodine]
What is pericoronitis, causes and risk factors. Who is more likely to get it
What it is= swelling and infection in the gingiva or operculum overlying the molars/ wisdom teeth
Causes= Bacteria, food debris and plaque accumulates under and around the tissue, causing inflammation.
Risk factors= partially impacted, poor oral hygiene, excess gum tissue, stress, pregnancy.
common in partially impacted molars. More common in lower than upper. Common ages 20-29,
Pericoronitis symptoms, complications, management and prevention
-Signs and symptoms= severe pain, swollen and red tissue, pain when swallowing, discharge of pus, trismus, pain when biting, loss of appetite. Chronic can include bad breath, bad taste, achy pain, fever
-Complications= Ludwig’s angina – infection spread to floor of mouth in the glands and nodes and neck and head. Or Sepsis -systemic infection in blood
-Management= cleaning the tissue (CHX irrigation). If systemic antibiotics (metranidazole). Having the flap/ operculum removed, extraction . At home use painkillers, warm salt-water rinses.
-Prevention= good oral hygiene
Defintion of analgesia and anaesthetic. Which is LA classed as
Anaesthesia = loss of perception of pain, touch, pressure, temperature, motor function
Analgesia = loss of perception of pain
LA = sits between these. no pain, light touch or temperature. Still feel pressure and motor function
Describe what nerves innervate the pulp/ palatal/ buccal tissues of maxillary 1, 2 and 3
1and 2= anterior superior alveolar nerve (of CNV2) for pulp and buccal. Nasopalatine nerve for palatal
3= same but greater palatine nerve for palatal
Describe innervation of pulp/ buccal/ palatal of maxillary 4-8
4 and 5 = middle superior alveolar nerve for pulp and buccal. Palatal is greater palatine
6-8= posterior superior alveolar nerve for pulp and buccal. Greater palatine
Describe innervation of mandibular pulp/ buccal/ lingual for 1-3
pulp= inferior alveolar nerve
lingual= lingual nerve
buccal= mental nerve of IAN
Describe innervation of mandibular pulp/ buccal/ lingual for all teeth
1-5= pulp IAN, lingual nerve, mental nerve of IAN (buccal)
6-8= pulp IAN, lingual nerve, long buccal nerve
What is Ringer’s solution
Contained in LA solution and acts as the solvent
What is a vasoconstrictor used for in LA. What prevents it breaking down
causes constriction of vessels to prolong the actions, reduce operative haemorrhage and reduce systemic effects
-a reducing agent prevents the vasoconstrictor breaking down
Faults that occur in/on a cartridge that would need throwing out
-Passed expiry date, cloudy solution, unreadable, glass fractured, large air bubble
What LA info is required in patient notes
Drug name, concentration and adrenaline, amount used, technique/ site, batch number, expiry date, aspiration positive or negative
What needle lengths and gauge sizes are there
10/25/35mm
27 or 30 gauge
When to avoid LA with adrenaline and when to reduce
Reduce or avoid adrenaline dose if CVD, drug interactions, compromised blood supply. But if no adrenaline, then LA less likely to work so heart could be affected when patient feels lots of pain
-reduce to 2-3 cartridges if tricyclic antidepressants, cardiac beta blockers, diuretics.
-avoid recreational drugs for 24 hours